Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Boulevard Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with medical devices, as staff did not use isolation gowns during care. Additionally, a resident on dialysis lacked a care plan for EBP. The facility also failed to maintain sanitary conditions in laundry services, with debris in dirty laundry bins and potential contamination risks in the clean laundry room.
The facility failed to maintain dignity during meal assistance for two residents with cognitive impairments. A CNA was observed standing while feeding a resident in a wheelchair and another in bed, which was acknowledged by the DON as inappropriate.
The facility failed to care plan for a resident's dentures, did not document dialysis access site conditions for another resident, and did not implement behavioral interventions during dining for a third resident. A resident was observed without dentures despite needing them, another resident's dialysis care plan lacked documentation, and a third resident's behavior during meals was not managed as per the care plan.
A resident with severe cognitive impairment and fragile skin suffered a skin tear due to a jagged tear on the wheelchair's leg rest. The injury was observed while the resident was in a lounge area, and the resident's significant other and an LPN acknowledged the hazard posed by the damaged wheelchair component.
A facility failed to identify and manage a resident's urinary catheter, leading to a deficiency. The resident, with mild cognitive impairment, had an indwelling catheter and refused its discontinuation without physician notification. Staff interviews revealed a lack of awareness about the catheter, with an LPN confirming its presence only after observation. This indicates a communication and documentation failure.
The facility failed to follow physician orders for dialysis care by taking blood pressure readings on the dialysis access extremity for three residents. Despite clear orders and care plan interventions, staff repeatedly took blood pressure readings on the affected arms of residents with AV fistulas. Additionally, one resident did not have a documented order for dialysis, yet received such services.
The facility failed to properly reconcile medications for two residents, leading to discrepancies in the administration of Temazepam and Tramadol. Nurses administered discontinued Temazepam 30 MG capsules while documenting under a 15 MG order, and Tramadol was recorded as given before it was received from the pharmacy. These errors were confirmed during medication reconciliation observations.
Failure to Implement Enhanced Barrier Precautions and Maintain Sanitary Laundry Conditions
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) for several residents, as observed during a survey. Resident #41, who had an indwelling urinary catheter, was evaluated by a physical therapist without the use of an isolation gown, despite an order for EBP. Similarly, Resident #388, who had a feeding tube and severe cognitive impairment, was assisted with feeding by a CNA who did not wear an isolation gown, contrary to the EBP order. Additionally, Resident #477, who had a history of infection and a dialysis catheter, did not have a care plan that included EBP, despite having an order for it. Resident #58, who had an indwelling catheter and mild cognitive impairment, did not have documentation or signage for EBP, even though the resident was known to resist care and manage the catheter independently. This lack of documentation and signage indicates a failure to implement necessary precautions for infection control. The absence of a care plan for EBP for residents with specific medical devices or conditions highlights a significant oversight in the facility's infection prevention protocols. The facility also failed to maintain sanitary conditions in the laundry services. Observations revealed that dirty laundry bins contained debris, and there was potential for cross-contamination due to unbagged laundry items and a torn vinyl cover on a laundry cart. Additionally, condensation from an air conditioner in the clean laundry room posed a risk of contaminating clean laundry. These findings suggest lapses in maintaining hygiene standards in the facility's laundry operations, further compromising infection control efforts.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain the dignity of two residents during meal assistance. Resident #388, who has severe cognitive impairment and is dependent on assistance for daily living activities, was observed during lunchtime sitting in a wheelchair next to his bed. A CNA was seen standing and leaning over the resident to feed him, which is not a dignified manner of assistance. Similarly, Resident #387, with moderate cognitive impairment and requiring substantial assistance, was observed in bed being fed by the same CNA who was standing next to the resident. The Director of Nursing acknowledged that staff should not be standing while assisting residents with meals.
Care Planning Deficiencies in Dental, Dialysis, and Dining Behavior
Penalty
Summary
The facility failed to adequately care plan for the dental needs of a resident, the dialysis care of another resident, and the behavioral interventions during dining for a third resident. Resident #34, who was cognitively intact and dependent on activities of daily living, was observed without teeth or dentures, despite stating a need for dentures. The Social Services Director confirmed that there was no care plan addressing the resident's need for dentures, even though the dentures were reportedly at the resident's bedside. Resident #387, who had moderate cognitive impairment and required substantial assistance with daily activities, was receiving dialysis services. However, the care plan for dialysis therapy was not fully implemented, as there was no documentation of the resident's access site condition before leaving and upon returning from dialysis. Additionally, Resident #66, who had morbid obesity, dementia, and cognitive communication deficit, exhibited behaviors during meals that were not addressed by staff. Despite a care plan intervention to redirect the resident during meals, staff failed to do so when Resident #66 ate food from another resident's plate on two separate occasions.
Failure to Maintain Wheelchair Leads to Resident's Skin Tear
Penalty
Summary
The facility failed to maintain a resident's wheelchair in a manner that prevented accidents, resulting in a skin tear for a resident with severe cognitive impairment and dependency for activities of daily living. The resident was observed with a bleeding skin tear on the left outer calf while sitting in a wheelchair in a lounge area. The resident's significant other noticed the injury and pointed out a tear on the wheelchair's left leg rest, which was rigid and jagged, directly adjacent to the resident's fresh skin tear. Staff K, an LPN, acknowledged the jagged tear on the wheelchair leg rest and noted the resident's fragile skin, indicating awareness of the potential hazard posed by the damaged wheelchair component.
Failure to Identify and Manage Urinary Catheter
Penalty
Summary
The facility failed to properly identify and manage a resident with a urinary catheter, leading to a deficiency in care. Resident #58, who was admitted with mild cognitive impairment and required substantial assistance with daily activities, had an indwelling urinary catheter. Despite an order for a urology follow-up and instructions to discontinue the catheter if the resident had not voided in six hours, the resident refused the discontinuation, and there was no documentation of physician notification. Additionally, the facility did not initiate a urology consult as ordered. Interviews with staff revealed a lack of awareness regarding the resident's catheter status. A CNA and an LPN both initially stated that the resident did not have a urinary catheter, but upon observation, the LPN confirmed the presence of the catheter. This discrepancy highlights a communication and documentation failure within the facility, as the resident was managing the catheter independently without proper oversight or adherence to medical orders.
Failure to Follow Dialysis Care Orders
Penalty
Summary
The facility failed to adhere to physician orders regarding the care of residents requiring dialysis, specifically by taking blood pressure readings on the dialysis access extremity for three residents. Resident #128, diagnosed with End Stage Renal Disease, had multiple blood pressure readings taken from the right arm, which had an arterio-venous (AV) fistula, despite clear orders and care plan interventions to avoid such actions. These readings were primarily conducted by Staff A, RN, and Staff H, LPN, over a period of several days. Similarly, Resident #442, also with End Stage Renal Disease, had blood pressure readings taken on the right arm, contrary to physician orders and care plan interventions. Staff H, LPN, was responsible for these readings. Additionally, Resident #387, who required dialysis services, did not have a documented order for dialysis, and blood pressure readings were frequently taken on the left arm, which was against the care plan intervention. The Unit Manager acknowledged these deficiencies during an interview.
Medication Reconciliation Failures for Two Residents
Penalty
Summary
The facility failed to adhere to professional standards for controlled substances reconciliation for two residents. For the first resident, there were discrepancies in the administration of Temazepam, a medication prescribed for insomnia. The resident had two different physician orders for Temazepam, one for 30 MG and another for 15 MG. Despite the 30 MG order being discontinued, nurses continued to administer the 30 MG capsules and documented the administration under the 15 MG order in the Medication Administration Record (MAR). This inconsistency was confirmed during a medication reconciliation observation, where it was noted that the nurses were signing off on the 30 MG medication control sheet but recording the administration in the 15 MG section of the MAR. For the second resident, there was an error in the documentation of Tramadol administration. The MAR indicated that Tramadol was administered before the medication was received from the pharmacy. Specifically, the MAR showed that Tramadol was given on a date prior to the receipt of the medication dispenser card containing the tablets. This discrepancy was acknowledged by a staff member during a medication reconciliation observation, who confirmed that the date was recorded incorrectly. These findings highlight a failure in the facility's medication reconciliation process, leading to potential medication administration errors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Boynton Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Isles Of Boynton Nursing And Rehab Center | 1.3 mi | ★★★★★ | 9 | 0 |
| Heartland Nursing & Rehab Center | 2.7 mi | ★★★★★ | 1 | 0 |
| Boynton Beach Rehabilitation Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Harbours Edge | 4.4 mi | ★★★★★ | 0 | 0 |
| Cascades Health And Rehabilitation Center | 4.4 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.